Form CMS-10676 Medicare.gov Sitewide Qualtrics Survey

Medicare.gov Site Satisfaction Survey

OMB# 0938-1185

Expires: (XX/XX/XXXX))

Thank you for spending some time to help us improve Medicare.gov today. Your opinions and feedback are very important to us! This survey will take you 3-5 minutes to complete. We appreciate your thoughtful responses.

Q1: (Ask all) Which of these best describes you?

1. I have Medicare, and I’m using Medicare.gov for myself (Ask Q1a) (Auto-code as beneficiary)

2. I have Medicare, and I’m using Medicare.gov for someone else (Ask Q1b)

3. I don’t have Medicare (Ask Q2)

Q1a: (Ask if Q1 = 1) How do you currently get your Medicare coverage?

1. I have Original Medicare (also called 80/20 or Fee for Service Medicare)

2. I have a Medicare Advantage plan (like an HMO or PPO)

3. I’m not sure

Q1b: (Ask if Q1 = 2) For whom are you visiting Medicare.gov today?

1. A friend or relative who has Medicare (Auto-code as unpaid caregiver)

2. A friend or relative who will be getting Medicare soon (Auto-code as unpaid caregiver)

3. A person I’m helping as part of my job (Ask Q2)

4. Other (specify) (Ask Q2)

Q2: (Ask if: Q1 = 3) Were you looking at Medicare.gov today as a:

1. Healthcare provider or healthcare office staff

2. Unpaid caregiver to someone who has Medicare

3. Person who will be getting Medicare soon

4. Assistor, navigator, agent, or broker

5. SHIP counselor

6. Researcher

7. Other (specify)

Q3: (Ask all) What was the primary purpose of your visit to Medicare.gov today?

1. Get general information about Medicare and how it works (Ask Q3a)

2. (if Q1 = getting info for self) Get specific information about my Medicare coverage (Ask Q3b)

3. (if Q1 = getting info for someone else) Get specific information about another person’s Medicare coverage (Ask Q3b)

4. Find out if a test, item, or service is covered by Medicare (Go to Q4)

5. Look for, review, or compare Medicare plans (Ask Q3c)

6. Apply for Medicare online (Go to Q4)

7. Look for a healthcare provider, healthcare facility, or service provider (Ask Q3d)

8. Change, update, or share information with Medicare (Ask Q3e)

9. File a claim, appeal, or complaint (Go to Q4)

10. Review, download, or print materials or publications (Ask Q3f)

11. Other (specify)

Q3a. (Ask if Q3 = 1) Which of the following best describes the type of information you were looking for today?

1. When can a person get Medicare? Or how do they apply?

2. What are the different Parts of Medicare (Part A, Part B, Part C, Part D)?

3. What are the different Medicare coverage choices?

4. Finding out about what Medicare costs (like premiums, deductibles, and copayments)

5. Look for, review, or compare Medicare plans

6. How does Medicare work with other insurance?

7. Other (Specify)

Q3b: (Ask if Q3 = 2 or 3) What specific information were you looking for today?

1. Review eMSN (Medicare Summary Notice)

2. Find the status of a claim

3. (if Q1 = getting info for self) Find my Medicare number

4. (if Q1 = getting info for someone else) Find another person’s Medicare number

5. Find out when new Medicare Cards will be mailed

6. (if Q1 = getting info for self) Look at my Medicare plan information (like my Part D or Medicare Advantage plan)

7. (if Q1 = getting info for someone else) Look at someone else’s Medicare plan information (like Part D or Medicare Advantage plan)

8. (if Q1 = getting info for self) Find out if I have met my deductible

9. (if Q1 = getting info for someone else) Find out if another person has met his or her deductible

10. Other (Specify)

Q3c: (Ask if Q3 = 5) What type of plan or plans were you interested in looking for, reviewing, or comparing? [select all that apply]

1. Medicare Advantage plans

2. Drug plans (Part D)

3. Medigap or supplement plans

4. I don’t know

5. Other (specify)

Q3d: (Ask if Q3 = 7) What, specifically, were you looking for today?

1. Doctors and other health professionals

2. Nursing home

3. Hospital

4. Home health services

5. Dialysis facility

6. Suppliers of medical equipment and supplies

7. Long-term care hospitals

8. Inpatient rehabilitation facilities

9. Hospice care

10. Other (specify)

Q3e: (Ask if Q3 = 8) What type of information were you changing, updating, or sharing with Medicare?

1. Address change

2. Name change

3. Email address change

4. Change how you get your MSN or Medicare & You handbook (by email or by mail)

5. Report that a person with Medicare has died

6. Other (specify)

Q3f: (if Q3 = 10) What materials or publications did you come to Medicare.gov to review, download, or print?

1. Medicare & You handbook

2. Medicare Summary Notice

3. Brochures, posters, or handouts

4. Data

5. New Medicare Card

6. Other (Specify)

Q4: (Ask all) Were you able to successfully {Q3 RESPONSE} during your visit today?

1. Yes (Skip to Q5)

2. No (Ask Q4a)

3. I don’t know (Ask Q4a)

Q4a: What will you do next to {Q3 RESPONSE}?

1. Come back to Medicare.gov at a later time

2. Go to a different website

3. Contact 1-800-MEDICARE

4. Get in-person help

5. Check the Medicare & You handbook

6. Other (specify)

Q5: (Ask all)

How satisfied were you with the following?	Very Satisfied (1)	Somewhat Satisfied (2)	Not Very Satisfied (3)	Not at all Satisfied (4)
a. Your overall experience today on Medicare.gov
b. The information provided on Medicare.gov
c. How well the Medicare.gov website worked today

Q6: (Ask all) How likely will you be to return to Medicare.gov if you need information about Medicare in the future?

1. Very likely

2. Somewhat likely

3. Not very likely

4. Not at all likely

5. I don’t know

Q7: (Ask all) How easy would you say it was for you to {Q3 RESPONSE} on Medicare.gov today?

1. Very easy

2. Somewhat easy

3. Somewhat difficult

4. Very difficult

5. I don’t know

Those are all of the questions we have. Thank you for participating in our survey.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1185 (Expires 04/30/2019).  The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure****  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Aileah St. Louis at 410-786-5052.

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